Many Mass. hospitals will pay for errors

Federal resistance to fees forces review

By Liz Kowalczyk, Globe Staff | September 17, 2007

About half of Massachusetts hospitals say they have adopted policies to waive charges for serious medical errors such as wrong-site surgery and harmful medication mistakes, and others say they plan to, amid growing resistance from government and health insurers to paying for poor outcomes.

Thirty-three of 61 hospitals recently reported to a national hospital-quality organization, The Leapfrog Group, that they have voluntarily stopped charging for 28 serious and rare errors, called "never events." But consumer groups, health insurers, legislators, and employers are pushing for more far-reaching and mandatory policies as ways to reduce errors, and hospital executives said they expect to forgo payments in an increasing number of cases, including those in which patients require additional treatment because they contracted an infection in the hospital or fell in their room.

In some cases, hospitals will not have a choice. Medicare, the federal insurance program for the elderly and disabled, decided last month that, beginning in October 2008, it will no longer pay hospi tals for care resulting from eight complications, including falls, objects left inside patients during surgery, pressure ulcers, and three types of hospital-acquired infections. Medicare hopes to encourage hospitals to do more to prevent these errors. Insurers often follow Medicare's lead, and the three largest Massachusetts insurers said they are reviewing the issue.

State Senator Richard T. Moore, an Uxbridge Democrat, has filed legislation that would, among other measures, prohibit hospitals from charging for "never events," which were developed by the National Quality Forum, a nonprofit organization based in Washington, D.C.

In addition to wrong-site surgery and serious medication errors, never events include leaving a foreign object in a surgery patient, discharging a baby to the wrong mother, and falls that result in death or serious disability. This summer, The Leapfrog Group, a Washington-based coalition mostly of large employers, began posting on its website which hospitals handle never events appropriately, including waiving charges.

Beth Israel Deaconess Medical Center, Caritas Christi Health Care, Cambridge Health Alliance, and Tufts-New England Medical Center are among those listed as waiving costs directly related to never events. Massachusetts General Hospital, Brigham and Women's Hospital, Lahey Clinic, UMass Memorial Health Care, and Children's Hospital Boston do not have such policies yet - though many hospitals waive costs in cases where the mistake is egregious and clearly caregivers' fault.

"Why should we pay for something that a hospital has allowed, through lack of action or lack of adequate personnel, to happen under their watch?" Moore said.

But doctors and hospital executives who are struggling to develop policies said it is not that simple. Even hospitals with policies do not always agree on what constitutes a never event or what costs to waive.

Dr. George Thibault, vice president for clinical affairs for Partners HealthCare, the parent organization of Mass. General and the Brigham, said that while hospitals may be able to eliminate some errors - surgery on the wrong body part or the wrong patient, for example - others are not always avoidable or the fault of caregivers.

"It's impossible for us to say we're never going to have a medication error," he said. "They are too complicated, and there are too many moving parts."

Exactly what constitutes a never event also is vague, he said. The Leapfrog Group said hospitals should not charge for care of patients who die or sustain "serious disability" from a fall in the hospital. "Does this include if you were in the ICU one day and then all right, or is it that you went home with a permanent disability?" Thibault asked. "And what about if you need ongoing care? If the patient is paralyzed and has to go to [rehabilitation], do we waive that too?"

"Some people think Medicare went a little too far," he added. "They've included some things on the list that are not absolutely preventable."

Medical leaders from Partners' hospitals are developing a policy on when to waive charges. Meanwhile, decisions are made on a case-by-case basis, he said.

Virginia Harvey's case highlights the thorny issues involved in these decisions. Harvey, 47, broke two bones in her left ankle stepping off a curb in Boston in 1996, requiring two operations at the Brigham. After the second surgery, her ankle became infected - an infection she believes she contracted in the hospital.

The staphylococcus infection ate away parts of her ankle and crept up her shin, Harvey said, and by 2000 she had undergone 26 additional surgeries, 15 at the Brigham. Eventually she switched to Beth Israel Deaconess, where surgeons amputated her leg below the knee. The infection has caused other medical problems, and Harvey still takes medication and wears a prosthetic leg and foot.

Harvey said her insurance covered most of the cost of her care, but believes the Brigham should have waived some bills.

But should the Brigham waive only the cost of the 17 surgeries there? Or should the hospital cover the cost of the surgeries at Beth Israel Deaconess, too? One of her hospital bills there, Harvey said, totaled more than $230,000. What about her time lost at work as an office manager at Harvard Law School? And what about her ongoing care? She has paid $18,000 so far out of her own pocket and with money raised by friends for three prostheses, and she will need new ones as she ages.

Dr. Andy Whittemore, the Brigham's chief medical officer, said he is not sure how the hospital would handle a similar case today. But it is clear the hospital would first try to determine whether the infection was caused during surgery or whether she somehow contracted it after she was discharged. "We're prepared to reimburse for clear-cut events," he said.

Leapfrog executives say never events should be rare, but when they do happen they can be expensive. While hospitals are required to report some serious errors to the Massachusetts Department of Public Health, the agency does not routinely make the data public, though Moore's bill would require disclosure of never events.

In Minnesota, where hospitals are required to report 27 types of serious errors, 154 errors were recorded in the most recent fiscal year. The most common mistakes were pressure ulcers, objects left inside patients during surgery, and wrong-site surgery.

In a study published last fall in the journal Health Affairs, researchers estimated the extra cost of treating serious errors ranged from an average of $700 per case for pressure ulcers, which are bed sores, to an average of $9,000 per case for post-surgery sepsis, a serious whole-body infection.

Dr. Walter Ettinger, president of UMass Memorial Medical Center, said the hospital charges for most complications from care now, but is developing a policy that would waive more charges.

"Most people don't want to have these complications and infections. They're terrible," he said. But "hospitals and doctors should be paid fairly for their services. Some people get up and go to the bathroom and fall even though they're told they shouldn't get up. A better way is for hospitals to have to reduce these [bad outcomes] to a very low level."

He and other doctors said costs that are waived will have to be covered somehow. "They will be passed on to someone ultimately," Ettinger said.

Moore sees another possible outcome: The threat of nonpayment will be so powerful that hospitals will find ways to dramatically reduce poor outcomes.